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1 <br /> San Joaquin County Environmental Health Department <br /> VI�ELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1399 E. Turner Road, Lodi, CA PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm thc t I am I�censed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: V&W Drilling, Inc. <br /> License#: 7209 <br /> Expiration Date: 4/30/2020 <br /> Signature: Title: Pres'dent <br /> Print Name: Karli R nae Stroing Date: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have a d will maintain a certificate of consent to self-insure for workers' compensation, as <br /> 13 provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued.) <br /> I have a d will maintain workers' compensation insurance, as required by Section 3700 of the <br /> R Labor C de,for the performance of the work for which this permit is issued. My workers' <br /> compeni ation insurance carrier and policy numbers are: <br /> Carrier: State Fu d j Policy#: 9115022-19 Exp. Date: 10/2/2020 <br /> I certify that in the erform nce of the work for-whikh this permit is issued I shall not employ p y an y person in <br /> any manner so a to become subject to t work s' compen ation law of California, and agree that if I <br /> should becomes bject to workers' com satin provisions If Section 3700 of the Labor Code, I shall <br /> fifthwith c6TplVwith,,those p ovisions. <br /> Signature: <br /> Print Name: Karli Renae Stroing <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDIT104 TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROI IDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHOR ZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, Karli Renae Str ing , hereb v(a P� r OV �v�to sign this Sa Joaquin C my Well &Boring Pe miJor,i,ze <br /> ppcation on my behalf. I understand this <br /> authorization is validfor one e r and <br /> Ii <br /> to the or Ian dated on the front page of this application. <br /> END 29-016-23-2015 Site Mitigation Well Permit Application <br />